PROCEEDINGS
rigidly
in a position
osteotomy
in plaster
maintained.
of flexion
at C.3-4
after
AND
and
level with
two
weeks,
REPORTS
rotation
25-degree
was
able
OF
to the
left,
correction
to see ahead
COUNCILS
with
AND
the
was performed
and
felt
more
axis
641
ASSOCIATIONS
parallel
to the
in December
balanced.
The
ground.
1957.
Patient
improvement
Cervical
walked
has
been
Case 2-Woman
aged thirty-three.
Sanatorium
treatment
for pulmonary
tuberculosis
in 1944, with
thoracoplasty
five years
later.
Onset
of ankylosing
spondylitis
in 1953, with marked
rigid cervical
kyphosis.
The vital
capacity
was only
880 cubic
centimetres.
The deformity
was so severe
that
atlanto-axial
dislocation
seemed
imminent.
Operation
was undertaken
at C.3-4
level with correction
as shown
(Figs.
I and 2). Three
weeks
later she collapsed
and died from
heart
failure.
Necropsy
showed
that the osteotomy
had caused
no nerve
root or spinal
cord
injury
and that death
was the
result
of her general
debility.
Yours
truly,
W. ALEXANDER
LAW.
NAIL-PLATE
FIXATION
From
To
the
Editor
of the
Journal
Mr
of Bone
G.
FOR
K.
and
TROCHANTERIC
MCKEE,
Joint
NORWICH,
FRACTURES
ENGLAND
Surgery:
SIR,
lt seems
that there are conflicting
statements
in the article
by Foster
on “ Trochanteric
Fractures
of the Femur
Treated
by the Vitallium
McLaughlin
Nail and Plate “ (November
1958 issue) and the
one by Bremner
and Graham
on “ Treatment
of Pertrochanteric
and Basal
Fractures
of the Femur
by Immediate
Fixation
with a Two-piece
Nail and Plate “ in the same issue.
Foster
suggested
from
studies
of the bending
moment
that
the McKee
type of nail-plate
had
about
one-fifth
of the strength
of the others.
Bremner
and Graham
stated
that “ in no instance
did
the McKee
nail and plate break
or bend,
nor did the screws
lose their
grip “ ; this was in a series of 100 cases.
This
corresponds
to my experience
over the last fifteen
years.
I
have occasionally
found
that the nail has bent, but not the
plate;
and if the nail does bend the site at which
the bending
takes
place
is beyond
its entry
into the bone (Fig.
I).
The discrepancy
between
the experimental
observations
of Foster
and the practical
records
of Bremner
and Graham
is probably
only apparent.
Both
findings
may
represent
the truth,
and
the explanation
lies in the fact
that
the
experimental
conditions
used by Foster
do not usually
apply
to the condition
encountered
in the body.
If the lateral
femoral
cortex
is intact
there
is a strong
piece
of bone
bridging
the angle between
the nail and the plate which
acts
like a fulcrum
on the nail and converts
the bending
strain
on the nail-plate
junction
into a tension
strain
which
the
metal
of the plate
is well able
to withstand,
the bending
strain
being
on the part of the nail inside
the bone
beyond
the fulcrum
(the lateral
femoral
cortex)
(Fig.
I).
At this
point
let me stress
the importance
of inserting
the nail as
vertically
as possible-i
aim so as to lessen this
35 degrees
or more should
be the
bending
strain on the nail itself.
If the lateral
femoral
cortex
is involved
in the fracture,
or if during
insertion
of the nail the lateral
femoral
cortex
splits
into
the fracture
line, the use of a plate
with slots
instead
of holes
is a great
safeguard
against
the bending
of
the
nail
or
nail-plate
deformity.
VOL.
41 B, NO.
junction
The
slots
allow
3,
AUGUST
1959
and
“
consequent
take-up
“
adduction
of
the
lower
McKee
nail-plate.
If the lateral
femoral
cortex
is intact the nail bends beyond
its
entry into the bone and not at the nailplate junction.
642
PROCEEDINGS
AND
REPORTS
OF
COUNCILS
AND
ASSOCIATIONS
fragment
so that
impaction
can take
place,
thus
taking
the strain
off the nail-plate
and favouring
consolidation
of the fracture.
(In fact I prefer to use slotted
plates as a routine
for these pertrochanteric
or basal
fractures
: not only do they allow
this essential
impaction
to take place in the unstable
type
of fracture,
but they also give a greater
choice
of position
in insertion
of the screws.)
FIG.
2
FIG.
3
McLaughlin
nail-plate.
Figure
2-Radiograph
immediately
after fixation
of a
fracture
with a four-flanged
McLaughlin
Vitallium
nail fixed by a stud and locking
nut to the usual McLaughlin
plate with an adjustable
slot. Figure 3-Three
months
later. In spite offirm
tightening
the nail-platejunction
has loosened
and given way
under the tension
strain, with consequent
adduction
deformity.
At first
replaced
by
adopted
in
relied
upon
there
is still
as shown
in
*
the nail-plate
that I introduced*
was held together
by a set-screw,
but this was soon
a threaded
stud on the nail and a locking
nut-an
improvement
which
has recently
been
the McLaughlin
nail-plate.
This modification
gives much
greater
security
and can be
to hold the nail and plate when
the fixation
hole is round
(as in the McKee
pattern)
but
a risk of giving
way if the hole is slotted
and adjustable
(as in the McLaughlin
pattern),
Figures
2 and 3.
Yours
truly,
G. K. MCKEE.
MCKEE,
G. K. (1944):
Trifin
Nail
and
Plate
for Pertrochanteric
THE
Fractures.
JOURNAL
OF
Lancet,
BONE
AND
i, 143.
JOINT
SURGERY